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Women and HIV

Adolescent Sexuality, Gender and the HIV Epidemic

Summer/Autumn 2001

Research from around the world shows a steady and significant increase in the rates of HIV infection among women, particularly women in Africa, Asia, Latin America, and the Caribbean. A significant proportion of HIV/AIDS cases occurs among young (15-29-year-old) women, meaning that many women with HIV were infected as adolescents.

Anatomical, biological, and other factors contribute to young women's heightened vulnerability to HIV/AIDS. Another variable, gender -- while routinely and automatically acknowledged as key -- goes beyond clinical and treatment issues, and even beyond anatomical male-female differences. Twenty years into the HIV/AIDS epidemic, gender and the role it plays remain unclear.

Gender identity encompasses sexual identity and is influenced by many social and cultural factors, which themselves change over time. Marina Laski, head of the AIDS department in the General Directorate of Women for the city of Buenos Aires, Argentina, explains that "power relations are constructed that are encouraged and legitimized by culture, defining the conduct expected of each gender as natural and giving way to gender stereotypes." Understanding gender can help determine opportunities and risks of many types for individuals, whether female or male.

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This edition of "Women and HIV" features a broad-based exploration of gender itself. Elucidating gender is essential to understanding how and why women, especially young women, are at particular risk for HIV infection. Similarly, improved knowledge about gender will help to formulate effective HIV prevention and even treatment strategies. Greater awareness of gender perspectives, reflected in such arenas as public policy, mass media, and health care, will enable women to take a more effective stand in situations that involve the risk of HIV transmission.

-- Leslie Hanna, Editor


A Patterned Vulnerability

Epidemiological studies across the developing world show that young people are not equally affected by HIV/AIDS: those who are most socially and economically disadvantaged are at highest risk. The risk of HIV infection for young people in developing countries is increased by sociocultural, political, and economic forces such as poverty, migration, war, and civil disturbance. Young people may also face the increased risks of HIV infection by virtue of their social position, unequal life chances, rigid and stereotypical gender roles, and poor access to education and health services.

Major changes over the last few decades have affected the sexual and reproductive health of young people in developing countries. Rapid urbanization and rural-urban migration has meant that greater numbers of young people are living in precarious and impoverished conditions. Traditional, multigenerational extended families have been increasingly replaced by nuclear [two-parent] families, single-parent families and, in some cases, the complete absence of parents. Young people are pressured to be sexually active and, in the case of boys, to have several different partners. Evidence from a variety of countries suggests that the age at which young people become sexually active may be falling. Certainly young people become sexually active at an early age in many countries. In Uganda, for example, almost 50% of young men and nearly 40% of young women recently surveyed reported having had sex by the age of 15 years. In Dar es Salaam, Tanzania, 60% of 14-year-old boys and 35% of girls have reported that they are sexually active. In a recent Brazilian school-based study, 36% of females reported having had intercourse by the age of 13 years. In parts of the world such as India, where there is sparse evidence about sexual activity among young people and where it is widely assumed that sexual initiation takes place within the context of marriage, recent studies show that approximately one in four unmarried adolescent boys report that they are sexually experienced.

In both developed and developing countries, a number of obstacles make it difficult for young people to protect their sexual and reproductive health. Young people often have less access to information, services, and resources than those who are older. Health services are rarely designed specifically to meet their needs, and health-care workers only occasionally receive specialist training in issues pertinent to adolescent sexual health. It is perhaps not surprising therefore that there are particularly low levels of health-promoting or -seeking behavior among young people. For example, even where they are able to recognize signs and symptoms of STDs, young people recently interviewed in Tanzania indicated that they were hesitant to go to public clinics or hospitals, but were more likely to treat themselves with over-the-counter medicines. Similarly, young people in a variety of contexts have reported difficulty accessing contraception and condoms. Most importantly, legislation and policies that prevent sex education from taking place, or that restrict its contents, prevent many young women and men from maximizing their sexual and reproductive health.


Images of Adolescence

One of the most important reasons why young people are denied adequate access to information, sexual health services, and protective resources such as condoms derives from the stereotypical and often contradictory ways in which they are viewed. It is popularly believed that all young people are "risk-taking pleasure-seekers who live only for the present." Such views tend to be reinforced by the uncritical use of the term adolescent (with its connotations of "storm and stress") in the specialist psychological and public health literatures. This term tends not only to homogenize and pathologize understandings of young people and their needs, but it also encourages a view of young people as possessing a series of deficits (in knowledge, attitudes, and skills) that need remedy by adults and their interventions.

Hoffman and Futterman have commented that adults often hold ambivalent attitudes toward young people, viewing them simultaneously as "small adults" and as "immature, inexperienced, and untrustworthy children." Many adults also have difficulty acknowledging adolescents as sexual beings, and therefore adolescent sexuality is viewed as something that must be controlled and restrained. These stereotypes have informed much HIV-related research and practice with young people. Warwick and Aggleton, for example, have described the central images found in the literature on young people and AIDS. These images include the "unknowledgeable or ill-informed adolescent," the "high-risk adolescent," the "adolescent who is unduly conforming to peer pressures," and the "tragic but innocent adolescent" who inadvertently becomes infected with HIV.

These powerful images and assumptions influence policy and practice in relation to young people and their sexual health. Some adults believe that young people are naturally sexually promiscuous, such that giving them information about sex will make them more sexually active. As a result, sex education in schools either does not take place or promotes only certain risk-reduction measures (most usually abstinence). Yet there is now clear evidence that well-designed programs of sex education, which include messages about safer sex as well as those about abstinence, may delay the onset of sexual activity, reduce the number of sexual partners, and increase contraceptive use among those who are already sexually active.

While formal health education programs have been influenced by stereotypical attitudes about young people's sexuality, parents and families across a wide variety of cultures have also sought to deny young people information about sex and reproduction. In countries as different as India and Nicaragua, parents and children report that they do not talk to each other about sex. Often parents and family members do this in the belief that they are protecting young people from information that they believe may lead to sexual experimentation. However, evidence suggests that young people who openly communicate about sexual matters with their parents, especially their mothers, are less likely to be sexually active or, in the case of girls, to become pregnant before marriage.

While young people have been commonly stereotyped as uniformly hedonistic and irresponsible, they are in fact a remarkably heterogeneous group. Their experiences vary widely according to cultural background, gender, sexuality, and socioeconomic status, among other variables. While some young people may take risks, the majority are at least as responsible as their parents, and some even more so. Moreover, it is important to recognize that in many developing countries, the onset of puberty signals greater economic and family responsibility rather than increased pleasure-seeking and risk-taking. That said, a number of structural as well as individual factors may heighten young people's vulnerability to HIV and AIDS.


Unequal Life Chances and HIV Infection

While developing countries in Asia, Africa, and South and Central America vary in terms of culture, religion, and socioeconomic factors, young people living in these regions share a number of experiences that render them particularly vulnerable to HIV infection. Access to education and information is often limited, levels of literacy lower, and poverty more prevalent. Young people living in poverty, or facing the threat of poverty, may be particularly vulnerable to sexual exploitation through the need to trade or sell sex in order to survive.

Estimates suggest that as many as 100 million young people under the age of 18 years live or work on the streets of urban areas throughout the world, heightening their risk of acquiring STDs including HIV. More than half of 141 street children interviewed in South Africa, for example, reported having exchanged sex for money, goods, or protection, and several indicated that they had been raped. Street children in Jakarta, Indonesia, have reported that being forced to have sex is one of the greatest problems that they face living on the streets. In Brazil, where an estimated seven million young people live on the streets, 1.5% to 7.5% of those tested for HIV are infected. In addition to risk from unprotected sexual activity, rape, and coercion, the high prevalence of injection drug use on the streets in Brazil and in some other countries may heighten young people's vulnerability to HIV.

Importantly, however, children and young people who live and work on the streets of urban areas do not commonly list HIV/AIDS as an overriding concern. Instead, the day-to-day needs for shelter, food, and clothes take higher priority. For young people struggling for daily survival, a disease like AIDS, which may or may not kill them for years to come, can seem unimportant.

Not only the most socioeconomically deprived children and young people in developing countries are vulnerable to sexual exploitation. Other young people living in precarious economic circumstances report having been forced to exchange sex for material benefit. For example, two-thirds of 168 sexually active young women interviewed in Malawi reported having exchanged sex for money or gifts, and 18% of 274 sexually active female Nigerian University students reported that they have exchanged sex for favors, money, or gifts.

Sometimes the exchange of sex for goods and money may be regularized in the form of what have been called "sugar daddy" and "sugar mommy" relationships. In Tanzania, young girls not infrequently report having older men or Mshefas (those who provide) as sexual partners. In Kenya, young girls report that they are courted by older men seeking sex, and may find themselves in situations difficult to negotiate.


Gender and Vulnerability

Stereotypical gender roles place young women, and to a lesser extent young men, at heightened risk of HIV infection. As mentioned earlier, young women in many parts of the developing world have little control over how, when, and where sex takes place. In perhaps the majority of countries, there are strong pressures on young unmarried women to retain their virginity. However, the social pressure to remain a virgin can contribute in a number of ways to the risks of STDs and HIV which young women face. In some contexts, young women may engage in risky sexual practices such as anal sex as a means of protecting their virginity.

The high social value placed on virginity in unmarried girls may pressure parents and the community to ensure that young women are kept ignorant about sexual matters. Female ignorance of sexual matters is often viewed as a sign of purity and innocence, while having "too much" knowledge about sex is a sign of "easy virtue." Young women in countries such as Thailand and Guatemala report that being knowledgeable about sex would compromise others' views of them.

This emphasis on so-called innocence prevents young women from seeking information about sex or services relating to their sexual health. Sexually active young women are also discouraged from discussing sex too openly with their own partners, since women are encouraged to be ignorant and inexperienced. Thus, young women are unlikely to be able to communicate their need for safer sex with partners. A Kenyan study revealed that young women felt that they did not have control over their sexuality -- instead, girls learned that sex was something that happened to them: it was not something they could initiate or actively participate in.

In addition to the emphasis widely placed on remaining "chaste," girls are commonly socialized to be submissive to men. Girls report often being pressured by boys to have sex as a proof of love and obedience. Not surprisingly, under conflicting pressures, girls have little influence over decision-making or the use of contraception. In a recent review of research conducted in seven countries including Nigeria, Egypt, Mexico, and the Philippines, Petchesky and Judd concluded that even where sexually active young women are aware of HIV/AIDS and measures to protect against infection, they rarely have the power to ensure that condoms are used.

While dominant ideologies of femininity promote ignorance, innocence, and virginity, dominant versions of masculinity encourage young men to seek sexual experience with a variety of partners. In some cultures, boys are actively encouraged by both their peers and family members to use their adolescent years to experiment sexually.

In Nicaragua, for example, where virginity is highly valued among young women, having multiple sexual partners is taken as a sign of virility in young men. Teenage boys face social pressures from older men (including fathers, older brothers, and uncles) to have sex as early as possible. In the recent past, it was not uncommon for Nicaraguan fathers to arrange for their son's sexual initiation with a sex worker. So while for girls, public disclosure of sexual activity leads to dishonor, bragging about sex is common for boys. Berglund and colleagues note that for young Nicaraguan men the pressure to be sexually active with multiple partners may be so great that those who do not fulfill this expectation are open to ridicule by their peers for not being "a real man."

Similar patterns prevail elsewhere in the world. In South Africa, for example, having many sexual partners is reported as being equated with popularity and importance among young men. Interviews with high school students in Zimbabwe indicate that while boys can have (and indeed should have) many girlfriends, girls should stick to one boyfriend. Although not all young men conform to the dominant versions of masculinity described above, those who fail to do so are often ridiculed and subjected to peer pressures to conform.

Homophobic bullying of the form that implies that any man who fails to conform to the dominant gender stereotype must be "homosexual" is but one of the many tactics employed in this process. Not only does such behavior stigmatize sexual minorities, it serves to police the boundaries of a heterosexual masculinity in which multiple partnerships with women become the norm.

While gender norms dictate that girls and women should remain poorly informed about sex and reproduction, young men are expected to be more knowledgeable, often as an indication of their sexual experience. However, research in a variety of contexts shows that they may be often poorly informed, but because sexual ignorance is not socially acceptable young men are reluctant to admit that they are lacking in knowledge. So while young women risk their sexual health because they must appear to be ignorant and so cannot openly seek information, young men risk their sexual health because they must appear to be knowledgeable and thus cannot openly seek information either.

The HIV/AIDS epidemic has served to further entrench some gender inequalities that place young women at increased risk of HIV infection. Central among these is the tendency for some older men to seek partners who are less likely to be sexually experienced or, in their eyes, infected with HIV. This places young women at increased risk of becoming infected by older men who may have wide sexual experience. Many young women who have HIV infection have had only one sexual partner, namely their husband. Furthermore, families affected by HIV/AIDS may seek economic security by marrying their very young daughters to older men. Doing so may have serious implications for the sexual and reproductive health of the young women concerned, and may also cut short their education and delay social development.


Sexuality and Vulnerability

While male-to-male sex exists in every culture, the activities concerned are rarely understood as "homosexual," and still less often as "gay." More likely than not, male-to-male sex will not be widely discussed, or named only within local vernaculars often inaccessible to outsiders. That said, in many countries of the world, a substantial number of young men have their first sexual experience with other men. For some this may be the beginning of a longer-lasting, bisexual behavioral repertoire. For example, 50% of male university students recently interviewed in Sri Lanka reported that their first sexual experience had been with another man, and there are well-documented studies of behavioral bisexuality among men in countries as diverse as the Philippines, India, Morocco, Brazil, the Dominican Republic, and Peru. While it would be inaccurate to view male bisexuality as a purely adolescent phenomenon or as triggered by men's lack of access to women, the restrictions many cultures place on socialization between the sexes may have an important role to play in facilitating this alternative means of sexual expression.

For a few young men, trading or selling sex to other men may offer a means of survival. In countries such as Sri Lanka, Thailand, Mexico, and Peru, male prostitution or sex work may take this form, with young men selling sex in order to provide for themselves and their families. Not all male sex workers are ignorant of the risks of STDs and HIV infection, and some may be better informed than other young people of a similar age. Still, not only is such behavior illegal and/or heavily stigmatized in many societies, the ability of young men to communicate and negotiate for safer sex with older male partners may be limited by inequalities of status and power. Where anal sex is practiced, the unavailability of condoms and lubricant may compound the risks some young men face.

Much less is known about current patterns of homosexual and bisexual behavior among young women, although such behaviors should be assumed to occur not only during youth and adolescence, but also for some women as part of a longer-lasting lifestyle. The role of such behavior in contributing to or protecting against HIV-related risk requires further investigation. It seems reasonable to suppose, however, that the stigmatized, denied, and marginal status of their behavior makes it difficult for young homosexually active women in developing countries to access the full range of information or resources to protect their sexual health.


Age and Vulnerability

Inequalities of age interact with the inequalities of socioeconomic background, gender, and sexuality to determine young people's vulnerability to STDs including HIV. As discussed earlier, this is the case for younger women who may be sought as sexual partners by older men in the belief that they are less likely to be infected. Yet age and generation just as strongly influence the vulnerability of young men, not only those who sell or trade sex, but also those who engage in sexual activity as a means of gaining adult status and the privileges it offers. For example, recent research in Tanzania has suggested that young men may attempt to address intragenerational inequalities through engaging in sexual activity, which represents adulthood and enhanced social status.

Beyond these behaviors -- which carry clear HIV-related risks -- are others no less embedded in local cultures and traditions. These include female genital mutilation (FGM) and male circumcision, both of which are perpetrated upon young people by those who are older. When practiced as part of group initiation ceremonies or in ways involving the sharing of razors, knives, and other cutting instruments, the risk of HIV infection being transmitted from one person to another can be considerable. The World Health Organization (WHO) and other bodies have condemned the practice of FGM on both medical and human rights grounds and, in 1993, passed a resolution at the 46th World Health Assembly calling for member states to act to eliminate harmful traditional practices. Where male circumcision continues to take place, it should be practiced in ways commensurate with the need both to prevent HIV and other blood-borne infections and the rights of young people to be involved in decisions about their bodies and what becomes of them.


Principles for Success

A number of principles can be identified for future work to prevent HIV infection among young people in developing countries:

  • Prevalent ideologies of masculinity and femininity that prescribe virginity in unmarried girls and promiscuity for boys facilitate the transmission of HIV to young women and young men. These ideologies need to be challenged at policy and program levels, as well as in the media, family, and community.

  • Negative stereotypes about young people and adolescent sexuality inform the attitudes of parents, other adults, and even those involved with HIV prevention. Wherever possible, program designers should attempt to challenge these stereotypes, since they serve as an obstacle to the development of appropriate and relevant programs of sex and HIV-related prevention.

  • Evidence suggests that young people across the world are having sex earlier than in the past. It is important then that sex and HIV-related education are provided in a timely manner. The widespread denial of adolescent sexuality leads to attempts by adults to constrain and control young people's sexual behavior. Since this is often unrealistic, it means that young people are denied access to information, services, and resources that help them to protect their health.

  • Young people benefit from open and honest communication with adults, something that is absent in many cultural contexts and declining in others. It is important that programs encourage better and more open forms of communication within families, and between families, communities, and young people. Some evidence suggests that the epidemic of HIV infection may itself provoke increased awareness among parents about the importance of helping young people to protect their sexual health.

  • Formal programs of sex education and HIV-related education are most successful when they include messages about safer sex as well as abstinence. Convincing messages that inform parents as well as policy makers that timely and relevant sex education does not propel young people into premature sexual relationships must be disseminated.

  • Teachers also require training in delivering sex education and developing confidence in talking to young people about sex. Supportive environments, including support from policy makers and educators, are important in helping teachers deliver effective programs of HIV-related education.

  • Evidence suggests that peer education programs support young people in making changes to their behavior.

  • Programs can provide opportunities to address issues relating to gender, social status, and sexuality in order to promote young people's sexual and reproductive health.

  • Program designers and others concerned with HIV infection must promote a greater awareness of structural issues affecting sexual and reproductive decision-making, including rights and protection for young people, as well as improved access to education and health services.

  • Young people living in developing countries, particularly girls and those young people living in especially precarious circumstances, need protection from rape and sexual exploitation and coercion. Communities and governments must mobilize to take action to ensure that all young people can enjoy increased safety and freedom from sexual abuse.

  • More work with young men is required to enable them to rethink their roles in relation to both their own sexual health and that of their partners, as well as improving programs for young women. Additionally, programs should target adult men (and the wider community) in order to help them to reduce the pressures on young men who are still developing their masculine identities.

  • Programs serving particularly vulnerable young people, including those who live on the streets, must address the daily risks that these persons face. Those concerned with the prevention of HIV also must work with policy makers to reduce the hardships faced by street children.

  • Work should be undertaken to reduce the marginalization of young men who have sex with other men, along with preventive work to ensure that young men are accurately informed and have access to health services and resources such as condoms.

  • Improved access to nonjudgmental and user-friendly sexual health services is crucial for young people. Training in adolescent health issues should be provided to health-care workers in the field of sexual and reproductive health.

Kim Rivers and Peter Aggleton are from the Thomas Coram Research Unit at the Institute of Education, University of London (UK).

The original text of this article and a complete listing of references can be found at www.undp.org/hiv/publications/gender/adolesce.htm.


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This article was provided by San Francisco AIDS Foundation. It is a part of the publication Bulletin of Experimental Treatments for AIDS. Visit San Francisco AIDS Foundation's Web site to find out more about their activities, publications and services.
 
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